LLR Equity and Equality Action Plan 2022-2027


In September 2021 NHS England/Improvement published The Equity and Equality – Guidance for local maternity systems and set out two aims relating to equity and equality for maternity & neonatal care:



  • To achieve equity for mothers and babies from Black, Asian and Mixed ethnic groups, and those living in the most deprived areas
  • To achieve equality and experience for staff from minority ethnic groups



The 1MBRRACE-UK report on maternal and perinatal mortality https://www.npeu.ox.ac.uk/mbrrace-uk/reports, shows worse outcomes for those from Black, Asian, and Mixed ethnic groups and those living in the most deprived areas.

Evidence from the UKOSS COVID study shows the disproportionate impact of Covid-19 on Black, Asian and ethnic minority pregnant women and those with other high-risk conditions and has highlighted the importance of continued focus in these group of women. Furthermore, in the NHS peoples plan, evidence suggests “…where an NHS workforce is representative of the community that it serves, patient care and…patient experience is more personalised and improves”.

If equity for mothers and babies is to improve, so must race equality for staff (NHS peoples plan). Whilst nationally there has been a small decrease in the maternal mortality rate for women from Black, Asian, and Mixed ethnic groups overall, there is still no substantive change in the disparity in mortality rates between women from Black ethnic groups and those from White ethnic groups, or between women from Asian ethnic groups and those from White ethnic groups.

LMNSs were asked to create the conditions to help achieve equity by considering the factors that will support high quality clinical care working with system partners and the VCSE sector to address the social determinants of health.

The maternity equity analysis and the maternity equity action plan are aligned to the five inequalities priorities outlined in the NHS Long Term Plan 2021/22 priorities and

operational planning guidance:

  • Priority 1: Restore NHS services inclusively
  • Priority 2: Mitigate against digital exclusion
  • Priority 3: Ensure datasets are complete and timely
  • Priority 4: Accelerate preventative programmes that engage those at greatest risk of poor health outcomes
  • Priority 5: Strengthen leadership and accountability.

Intervention 1 Implement Four Covid-19 Actions

Led by Community Midwifery Matron/ Covid lead/ Public health midwife/ consultant midwife from 2022-24

i) Implement operational policy for management of covid 19 for pregnant women from ethnic Minority backgrounds: Increase awareness amongst vulnerable groups by working with public health colleagues using targeted methods.

ii) To develop mechanism to link postcode/ethnicity and social deprivation to understand areas of highest need.

iii) Develop tools for those with limited understanding due language barrier or literacy limitation.

iv) Maternity Trust to routinely discuss and monitor vitamins, supplements, and nutrition in pregnancy with all women to help minimise the risk of Vitamin D insufficiency.

Intervention 1: ensure personalised care and support plans (PCSPs) are available in a range of languages and formats, including hard copy PCSPs for those experiencing digital exclusion.  

Led by Digital midwife, audit midwife, HOM from 2022-2024

i) Steps in place to ensure maximum number of women co-develop PCP with particular emphasis on those women who have language difficulties and/or are digitally excluded. Face to Face as well as digital offer.

ii) Develop and Implement Maternity Digital Strategy

iii) Monitor data collection with breakdown of who is accessing face to face, telephone, or video consultations, broken down by relevant protected characteristics and health inclusive group. (audit, inequalities dashboard)

iv) regular survey, patient feedback re the impact of digital consultations i.e.  Develop a mechanism for rapidly and effectively capturing patient reported experience and outcome measurements that considers equity and equality factors. 

Intervention 1: on maternity information systems continuously improve the data quality of ethnic coding and the mother’s postcode.

Led by Digital midwife, Consultant midwife, ICB LMNS Board and ICB Clinical maternity lead from 2022-2024

i) Data quality report that provides community teams intelligence for their cohort of women and missing data to then develop actions.

ii) To escalate data quality issues to ICB LMNS Board.

iii) To identify output from qualitative research around health inequalities in the women and children’s directorate.                                                                           
iv) Instigate regular data quality audits and checks.

v) Use LLR perinatal health inequalities dashboard to provide granular data at place and neighbourhood level.

vi) To develop robust monitoring of data submitted via MSDS supported by a dedicated individual with ongoing audit of as part of improving data quality – on maternity information systems continuously improve the data quality of ethnic coding and the mother’s postcode.                

4a Intervention 1- Understand populations and co-produced interventions 

Led by Public Health/ Digital Midwife during March 2023

i) To design interventions based on sound data.

ii) To ensure continuous involvement of services users in the design of interventions at place and neighbourhood level, and in co-producing strategies that effect change around existing perinatal health inequalities.

iii) Work to comms plan.

iv) Work with place-based partnerships /MVP and groups identified via VCSE.

v) Good understanding of need at system place and neighbourhood level. JSNA

vi) Actively have readily available clinical indicators social determinants.

vii) Identify PH leads and maternity leads to monitor.

viii) Utilise MSDS going forward alongside UHL dashboard.


4a Intervention 2: Map the community assets 

Led by Communications/Engagement teams, MNVP, Local Authorities and Health

Priorities and action planning 2022-2024

i) Scope and develop community assets register at place and neighbourhood level which all women and midwives can access.

ii) Instigate comms plan to cascade information.

iii) Work to Communication plan and link in with ICB workstream, community alliance, MVP, UHL community and specialist midwives

iv) Link with portal.

v) Develop a cascade community alliance model – (the ICB will develop alliances with voluntary sector organisations, social enterprises and communities which then, in turn, will form their own alliances to widen ICB reach and reach into the ICS).

vi) Link in LLR ICS People and Communities Strategy 2022-2024: A Strategy for the Leicester Leicestershire and Rutland (LLR) Integrated Care Board for working with people and communities.

vii) Implement comms plan, develop Marketing and Insights Hub and increase capacity and capability to interrogate high quality data


4a Intervention 3 – WRES, see 4d Intervention 3: Implement the Workforce Race Equality Standard (WRES) in maternity and neonatal services.


4a Intervention 3 – Cultural competency (see 4d Intervention 1 roll out multidisciplinary training about cultural competence in maternity and neonatal services.


4a Intervention 4 – co-production

Led by Screening and Immunisation Co-ordinator, Ante-natal screening midwife.

i) Scoping exercise to understand why women form certain ethnicities book late, do not take up the offer from screening/ vaccinations.

ii Complete scoping exercise via newly established T & F group set up to look at how to improve maternity access and experience for women from ethnic minority communities.

iii) Develop co-produced action plan to address recommendations from recent engagement exercise undertaken with women form BAME and socially deprived groups regarding their pregnancy experience.

iv) Link with key stakeholders including the screening teams; Covid vaccination teams; and Public Health to get the message across different communities why screening is important.

To be implemented in October 2023 by CYP & Maternity Senior Officer and Maternity Transformation Manager.

i) Scope evidenced based peer educators programme and put forward option/s for maternity, neonates.
ii) Link with university to set up programme.
iii) Secure funding. 

4b Intervention 1 (maternal medicine network/hubs)
Led by Clinical Director for Women & Children, Project Manager

i) Fully implements maternal medicine pathway that ensure women from Black and BAME communities are supported to access appropriate specialist services and outcome for this group are improved. collect data broken down by level of deprivation of the mother’s postcode and ethnicity.

ii) Funding in from other ICB’s in our region.

iii) Engage MVP and community assets to promote services and support access.


4b Intervention 2 – Diabetes

Led by Public Health, Maternity Diabetes Team, Specialist Midwife and ‘Healthy You’ Programme Leads from 2023-2024

i) Identify need for training and referral pathways for those eligible for the physical activity pre and post pregnancy service.

ii) Increase awareness of the Diabetes Prevention Programme through existing hospital diabetes teams, primary care sectors. Increase awareness of physical activity programme for pre and post pregnancy women.

iii)Increase in pre- and post-natal women meeting the CMO physical activity guidelines.

iv) Improving interoperability between different systems (Part of digital Strategy)


4b intervention 3 NICE CG110

Led by Safety Champions, Consultant Midwives, Senior Project Managers and Clinical System Co-ordinator from 2022-2023

i) Identified individual to monitor on regular bases data quality submitted by team onto maternity systems – and what data can be retrieved at regional measures report and MSDS.

ii) Digital midwife due to commence Oct 22. Interim have data analysis. Work with NHSE to monitor data quality; actively monitor data set for compliance with MSDS and where not possible Audits. Compliance with MSDS data set.


4b intervention 4 implement maternal mental health services with a focus on access by ethnicity and deprivation.

Led by Consultant Psychiatrist and Service Manager from 2023-2024

i) Analyse data to understand those that refuse access or DNA.

ii) Increase access. Utilise Service user feedback.   

iii) Monitor ethnicity, area of deprivation and other protected characteristics 

iv) To increase number of women accessing PMHS to 10% March 2023.  

  1. v) Identify individual to monitor data quality submitted by team onto maternity/mental health systems, and what data can be retrieved at regional measures report and MH MSDS


4b Intervention 5 PCP

Led by Consultant Midwife and Digital Midwife from 2023-2024

i) Promote importance of care plans for all women.

ii) Review of IT system to support Care planning.  Interim

iii) Analyst to monitor on regular bases data quality submitted by team onto maternity systems – and what data can be retrieved at regional measures report and MSDS.

iv) Carry out Audits to understand where gaps are for Ockendon report purposes where digital capability is not available. (E3 does not support recording of PCP at 17 week, 35weeks and 37 weeks with ethnicity and postcode.

v) Make available tools to those with limited understanding due language, literacy, special needs limitation. Ensure Maternity notes available as a printed copy as and when needed, to allow service users and care providers to have access to maternal notes at any given time?


4b Intervention 6 MVP

Led by Maternity Transformation Programme Manager, Consultant Midwife from 2023-2024

i) Option paper presented to LMNS Board and agree option. (To re-launch LLR MVP).

ii) Recruit Chair.

iii) Agree MVP recruitment, workplan.

iv) Ensure appropriate data collection and monitoring or MVP ethnicity and area of residence reflects the communities of LLR.

v)Develop a communication and engagement plan which involves the re-launch of the MVP and co-production of action plans.

4c Intervention 1 MCoC

Led by Consultant Midwife during 2024-2025

i) Consultant Midwife Lead to continue delivering evidenced based practice around MCoC, providing education and engagement with midwifery teams and wider MDT.

ii) Consultant Midwife to continue developing and making sure the building blocks for safe and sustainable transformation are in place, as set out in delivering midwifery MCoC at full scale and implement when workforce levels are safe.

iii) Work with Community interest groups and the MVP to look at how continuity of care would affect them, and how it would impact on their community. 75% of women from vulnerable, deprived backgrounds to be on some form of continuity, enhanced continuity pathway.

iv) Monitor birth outcomes for women from these groups.


4c Intervention 2 implement a smoke-free pregnancy pathway for mothers and their partners.

Ambika Dattani – Smoking Lead link with System Tobacco Strategy

i) Make available tools to those with limited understanding due language barrier or literacy limitation.

ii) Finalise pathway and recruit Tobacco advisors for inpatients.

iii) Complete guidelines for NRT prescribing as in patients.

iv) Implement robust referral pathway that link Maternity and public health systems.

v) Develop communication strategy for workforce internal and external of new pathways.

vi) Deliver training to workforce.


4c Intervention 3 Implement an LMS breastfeeding strategy and continuously improve breastfeeding rates for women living in the most deprived areas.

Led by UHL Breastfeeding Lead, Strategic Lead Maternal and Children’s Health

i) Work towards the implementation of a consistent shared approach across the LMNS informed by the UNICEF Baby Friendly model and Infant Feeding.

ii) Develop awareness plan with place based groups, MVP, VSCE groups

iii) Improve data quality

iv) Implement BFI Accreditation status across all maternity and neonatal units .

v) Improve uptake of breastfeeding at discharge. (Breastfeeding leads to Monitor uptake)

Intervention 1: roll out multidisciplinary training about cultural competence in maternity and neonatal services.

Led by Director of Nursing & Midwifery, System Equality & Diversity teams, Maternity, Educational Lead and Consultant Obstetrician during 2023-2024

i) Cultural competency courses to be explored, due to workforce capacity difficult to release staff to attend course. Funding will be explored through ICB, Trust workforce, OD mandatory training route.

ii) Explore Other options for cultural awareness including the offer from HEE online e-learning which was initially developed as part of the Mary Seacole Awards, created to improve communication and confidence of healthcare staff when dealing with patients.

iii) Training to be promoted through the LMNS the Trust providers, education teams and Comms.

iv) Develop mechanism to monitor % Staff who have received Cultural Competency Training. Equity Lead Midwife to work with cultural ambassadors and directors of midwifery to formalise training and make it an area of competence in yearly appraisals, as part of the KPIs.


4d Intervention 2: when investigating serious incidents, consider the impact of culture, ethnicity, and language.

Led by Safety Champions from 2023-2024

i) Record who is attending the RCAs review and their ethnicity.

ii)Look at capturing ethnicity on DATIX forms.

 iii) When investigating incidents check if culture, ethnicity, and language have been taken into account (HSIB and those on STEIS system)


4d Intervention 3: implement the Workforce Race Equality Standard (WRES) in maternity and neonatal services.

Led by Director of Nursing and Director of Midwifery, HOM, UHL Workforce and UHL Inequalities group from 2023-2024

i) WRES for Maternity and Neonates: undertake specific WRES for maternity and neonates, share results and develop workforce plans to address gaps.

ii) Embed a KPI as part of the appraisal process.

iii) Support and encourage LMNS process for each interview a member of the panel is required to be trained in equality diversion and inclusion. 

iv) Based on the annual WRES report, develop action plans to address workplace inequalities. incorporating the workplace ambassadors reporting to workforce committee quarterly.

v) Embed continuous accountability to ensure key policies have equality built into their core.

vi) Monitor number of staff from BAME community going through leadership programmes, opportunity, positions going forward.

Intervention 1: Establish community hubs in the areas with the greatest maternal and perinatal health needs.

Led by LA leads to link in with CYP and Maternity Services Senior Officer, Consultant Midwife, and Maternity Transformation Programme Manager

i) Ensure the inclusion of Maternity Services within Community/ Family Hubs.

ii) Work with system leads and co-produce with the relevant communities to establish community hubs in the areas with the greatest maternal and perinatal health needs.

iii)  Ensure MVP engagement with City and County and Rutland family hub pathway


4e Intervention 2: work with system partners and the VCSE sector to address the social determinants of health.

Led by Head of Engagement and Insights, MVP leads, and Perinatal Mental Health during 2022-2023

i) Strengthen links via VCSE to inform service development.

ii) Consider VCSE as a vehicle to support MVP recruitment.

iii)   Develop Peer Educator Programme? build on existing peer programme in perinatal mental health


Led by Consultant Midwife, Public Health midwife and Public Health from 2023-2024

Improve early booking and understanding of the screening process within key ethnic minorities and socially deprived groups.


Led by Public Health Midwife and Public Health across LLR from 2023-2024

Implement findings from the newly established T& F group looking to improve experience and access for BAME women and women from socially deprived groups. Agree key deliverable and source funding/buy in.

Skip to content